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Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2021;Epub Sept 13.
Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Liese KL, Davis-Floyd R, Stewart K, et al. Anthropol Med. 2021;28(2):188-204.
This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.
Levy FH, Conrad KA, Kemper C, et al. Pediatr Qual Saf. 2021;6(4):e449.
Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the United States. This article describes the development of the Child Health PSO and how it evolved into a learning network through alignment around a common goal, collaboration, and information sharing with high levels of engagement from participating children’s hospitals.
Rocha HM, Farre AGM, Santana Filho VJ. J Nurs Scholarsh. 2021;53(4):458-467.
Patient boarding in the emergency department (ED) can result in patient harm. This review explored the association between boarding in the ED and quality of care, outcomes, and adverse events. Increased boarding time was associated with poorer quality of care and outcomes.

Gangopadhyaya A. Washington DC; Urban Institute: July 2021.

Racial inequities have been revealed by the COVID pandemic as a distinct patient safety concern. This report examined racial differences using patient safety indicators to measure hospital-acquired conditions, insurance coverage, and hospital patient population. The results indicate Black patients have reduced safety, that insurance coverage had little influence on safety and hospitals with a higher Black patient population experienced more adverse events that those serving a white patient population.
Chalmers K, Gopinath V, Brownlee S, et al. JAMA Health Forum. 2021;2(7):e211719.
Overuse or low-value procedures may result in patient physical, psychological, or emotional harm. This study explored the association between eight low-value care procedures and length of stay (LOS) and cost. All eight procedures were associated with increased LOS and cost, particularly spinal fusion. Patients receiving low-value care may be exposed to increased risk of adverse events and hospital-acquired conditions.

National Association for Healthcare Quality.  August 26, 2021, 1:00–2:00 PM (eastern).

Communication and Resolution Programs (CRPs) are a successful multidisciplinary coordination strategy to align healing actions with the patient and family after medical error. This session will discuss the impact of CRPs and share program implementation insights. The session features Thomas H. Gallagher, MD, as a speaker.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined. Funding for this innovation was originally provided to the University of Missouri via a Centers for Medicare & Medicaid Services (CMS) demonstration grant. Given the success of the innovation, when the grant funding expired, the model and lessons learned from the initiative were transferred to NewPath Health Solutions, LLC, to ensure continued dissemination.

Barbara L, Roberta DB, Vanda R, et al. J Patient Saf. 2021;Epub May 20.
Patient safety indicators can help hospitals identify and prevent potential adverse events. Researchers in this study developed a conceptual framework for monitoring patient safety and a set of fifteen actionable patient safety indicators.

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Patient Safety Movement. September 17, 2021, 2:00-5:00 PM (eastern). 

Patient safety is a global challenge for the health care community. This webinar coincides with World Patient Safety Day and will present two tracks for both the profession and the public that highlight issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error will also be honored during the event. The session speakers include Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.  
Evans S, Green A, Roberson A, et al. J Pediatr Nurs. 2021;61:151-156.
A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU). The framework included both objective and subjective criteria. By identifying patients at increased risk of clinical deterioration (“watcher status”) and use of the framework, recognition of deterioration occurred sooner and resulted in fewer emergency transfers to the ICU.